Sandbox ID Cardiovascular

Aortitis, infectious

• Preferred regimen(1): Cefotaxime sodium 1.0 to 2.0 g IV qd.

• Preferred regimen (2): Ciprofloxacin hydrochloride 400 mg IV q12h OR Ciprofloxacin hydrochloride 500 to 750 mg orally q12h OR Levofloxacin 250 to 750 mg IV/oral qd.

• Preferred regimen (3): Oxacillin 1.0 to 2.0g IV or IM q4h / q6h OR Nafcillin 1.0 to 2.0 g IV or IM q4h / q6h OR Dicloxacillin 500 mg to 1.0 g IV or IM q4h /q6h

• Preferred regimen (4): Vancomycin 1.0 g (15 mg/kg, up to 3.0 to 4.0 g/d) IV q12h.

Note: Antimicrobial treatments are most effective when bactericidal, broadspectrum antibiotics are begun after obtaining blood cultures and prior to surgery. Dose of Cefotaxime sodium should be decreased by 50% in those with a creatinine clearance (CCr) of ≤ 20 mL/min. Ciprofloxacin should be used cautiously in those with a CCr ≤ 50 mL/min or when given concomitantly with drugs whose metabolism may be altered.

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Cardiovascular implantable electronic device infections

• Early post-implantation inflammation.

• Preferred regimen: Flucloxacillin 0.5–1 g oral q6h.

Note: Benefit of and need for antimicrobial therapy in early post-implantation inflammation is unclear.

• Early post-implantation inflammation in penicillin-allergic or MRSA-colonized patient

• Preferred regimen: Doxycycline 100 mg oral q12h OR Linezolid 600 mg oral q12h OR Clindamycin 450 mg oral q6h.

• Uncomplicated generator pocket infection

• Preferred regimen: Vancomycin 1 g IV q12h OR Daptomycin 4 mg/kg IV qd OR Teicoplanin 6 mg/kg to a maximum of 1 g given at 0, 12 and 24 h and then qd.

• ICED-LI or ICED-IE or complicated generator pocket infection pending blood cultures, e.g. in severe sepsis

• Preferred regimen: Vancomycin 1 g IV q12h AND Meropenem 1 g IV q8h OR Daptomycin 8–10 mg/kg IV qd AND Meropenem 1 g IV q8h.

• ICED-LI or ICED-IE or generator pocket infection with negative blood cultures

• Preferred regimen: Vancomycin 1 g IV q12h AND Gentamicin 1 mg/kg IV q12h OR Daptomycin 8–10 mg/kg IV qd AND Gentamicin 1 mg/kg IV q12h.

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Endocarditis, prophylaxis

• Antibiotic Prophylactic Regimens for Dental Procedures

• Oral regimen

• Preferred regimen: Amoxicillin 2 g single dose 30-60 minutes before procedure.
• Pediatric dose: 50 mg/kg single dose 30-60 minutes before procedure.

• Unable to take oral medication

• Preferred regimen: Ampicillin 2 g IM or IV single dose 30-60 minutes before procedure OR Cefazolin 1 g IM or IV single dose 30-60 minutes before procedure OR Ceftriaxone 1 g IM or IV single dose 30-60 minutes before procedure.
• Pediatric dose: Ampicillin 50 mg/kg; Cefazolin 50 mg/kg; Ceftriaxone 50 mg/kg

• Allergic to penicillins or ampicillin— Oral regimen

• Preferred regimen: Cephalexin 2 g single dose 30-60 minutes before procedure OR Clindamycin 600 mg single dose 30-60 minutes before procedure OR Azithromycin 500 mg single dose 30-60 minutes before procedure OR Clarithromycin 500 mg single dose 30-60 minutes before procedure.
• Pediatric dose: Cephalexin 50 mg/kg single; Clindamycin 20 mg/kg; Azithromycin 15 mg/kg OR Clarithromycin 15 mg/kg.

• Allergic to penicillins or ampicillin and unable to take oral medication

• Preferred regimen: Cefazolin 1 g IM or IV single dose 30-60 minutes before procedure OR Ceftriaxone 1 g IM or IV single dose 30-60 minutes before procedure OR Clindamycin 600 mg IM or IV.
• Pediatric dose: Cefazolin 50 mg/kg IM or IV OR Ceftriaxone 20 mg/kg IM or IV.

• Gastrointestinal/Genitourinary Procedures

• Antibiotic prophylaxis solely to prevent IE is no longer recommended for patients who undergo a GI or GU tract procedure.

Note: Routine administration of prophylactic antibiotics prior to GI and GU procedures including diagnostic esophagogastroduodenoscopy or colonoscopy is not recommended. However, for the high risk patients who already have an established GI or GU tract infection, it is reasonable to administer antibiotics against enterococci which includes the following: Ampicillin 2 g IM or IV single dose, piperacillin, or vancomycin.

• Regimens for Respiratory Tract Procedures

• Oral regimen

• Preferred regimen: Amoxicillin 2 g single dose 30-60 minutes before procedure.
• Pediatric dose: Amoxicillin 50 mg/kg single dose 30-60 minutes before procedure.

• Unable to take oral medication

• Preferred regimen: Ampicillin 2 g IM or IV OR Cefazolin 1 g IM or IV OR Ceftriaxone 1 g IM or IV.
• Pediatric dose: Ampicillin 50 mg/kg; Cefazolin 50 mg/kg; Ceftriaxone 50 mg/kg.

• Allergic to penicillins or ampicillin— Oral regimen

• Preferred regimen: Cephalexin 2 g single dose 30-60 minutes before procedure OR Clindamycin 600 mg single dose 30-60 minutes before procedure OR Azithromycin 500 mg single dose 30-60 minutes before procedure OR Clarithromycin 500 mg single dose 30-60 minutes before procedure.
• Pediatric dose: Cephalexin 50 mg/kg single; Clindamycin 20 mg/kg; Azithromycin or Clarithromycin 15 mg/kg.

• Allergic to penicillins or ampicillin and unable to take oral medication

• Preferred regimen: Cefazolin OR ceftriaxone 1 g IM or IV single dose 30-60 minutes before procedure OR Clindamycin 600 mg IM or IV.
• Pediatric dose: Cefazolin 50 mg/kg IM or IV OR Ceftriaxone 20 mg/kg IM or IV.

• Regimens for Procedures on Infected Skin, Skin Structure, or Musculoskeletal Tissue

• Patients who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against staphylococci and -hemolytic streptococci, such as an antistaphylococcal penicillin or a cephalosporin.

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Intravascular catheter-related infections

• Staphylococcus aureus

• Methicillin susceptible

• Preferred regimen: Naficillin 2 g 4th hourly OR Oxacillin, 2 g 4th hourly IV
• Alternative regimen: Cefazolin, 2 g TID; or Vancomycin, 15 mg/kg BID IV.

• Methicillin resistant Staphylococcus aureus

• Preferred regimen: Vancomycin, 15 mg/kg BD OR Daptomycin, 6–8 mg/kg per day, or Linezolid; OR Vancomycin AND (Rifampicin or Gentamycin); or TMP-SMZ alone (if susceptible).

• Coagulase-negative staphylococci

• Methicillin susceptible

• Preferred regimen: Naficillin, 2 g 4th hourly OR Oxacillin, 2 g 4th hourly.:::* Alternative regimen:
• Alternative regimen: First-generation Cephalosporin OR Vancomycin OR TMP-SMZ

• Methicillin resistant

• Preferred regimen: Vancomycin, 15 mg/kg IV BD
• Alternative regimen: Daptomycin 6 mg/kg per day OR linezolid

• Enterococcus faecalis/Enterococcus faecium

• Ampicillin susceptible

• Preferred regimen: Ampicillin, 2 g 4th hourly or 6th hourly;OR Ampicillin 1 mg/kg 8th hourly OR Gentamycin 1 mg/kg 8th hourly.
• Alternative regimen: Vancomycin

• Ampicillin resistant, Vancomycin susceptible

• Preferred regimen: Vancomycin, 15 mg/kg IV BD Template:With or without Gentamycin, 1 mg/kg TID
• Alternative regimen: Linezolid or Daptomycin 6 mg/kg per day.

• Ampicillin resistant, Vancomycin resistant

• Preferred regimen: Linezolid, 600 mg BD; OR Daptomycin 6 mg/kg per day
• Alternative regimen: Quinupristin/Dalfopristin 7.5 mg/kg TID

• Gram-negative bacilli

• Escherichia coli and Klebsiella species

• ESBL negative

• Preferred regimen: Ceftriaxone 1–2 g per day
• Altered regimen: Ciprofloxicin OR Aztreonam

• ESBL positive

• Preferred regimen: Ertapenem 1 g per day OR Imipenem 500 mg 6th hourly OR Meropenem 1 g 8th hourly OR Doripenem 500 mg 8th hourly
• Altered regimen: Ciprofloxicin OR Aztreonam

• Enterobacter species and Serratia marcescens

• Preferred regimen: Ertapenem 1 g per day OR Imipenem 500 mg 6th hourly OR Meropenem 1 g 8th hourly
• Altered regimen: Cefepime OR Ciprofloxacin

• Acinetobacter

• Preferred regimen: Ampicillin/Sulbactam 3 g 6th hourly OR Imipenem 500 mg 6th hourly OR Meropenem 1 g 8th hourly.

• Stenotrophomonas maltophilia

• Preferred regimen: Trimethoprim-sulfamethoxazole 3–5 mg/kg 8th hourly
• Altered regimen: Ticarcillin AND Clavulanate

• Pseudomonas aeruginosa

• Preferred regimen: Cefepime, 2 g 8th hourly OR Imipenem 500 mg 6th hourly OR Meropenem 1 g 8th hourly OR piperacillin and tazobactum 4.5 g 6th hourly OR Amikacin 15 mg/kg once a day OR Tobramycin 5–7 mg/kg once a day.

• Burkholderia cepacia

• Preferred regimen: Trimethoprim-sulfamethoxazole 3–5 mg/kg 8th hourly OR Imipenem 500 mg 6th hourly OR Meropenem 1g 8th hourly.

• Fungi

• Candida albicans or other Candida species

• Preferred regimen: Capsiofungin 70-mg loading dose, then 50 mg per day OR micafungin, 100 mg per day OR anidulafungin, 200 mg loading dose followed by 100 mg per day OR fluconazole, 400–600 mg per day.
• Altered regimen: Lipid amphotericin B preparations.

• Uncommon pathogens

• Corynebacterium jeikeium (group JK)

• Preferred regimen: Vancomycin 15 mg/kg twice daily
• Altered regimen: Linezolid

• Chryseobacterium (Flavobacterium)

• Preferred regimen: Levofloxacin 750 mg once daily.
• Altered regimen: Trimethoprim-sulfamethoxazole OR Imipenem OR Meropenem

• Ochrobacterium anthropi

• Preferred regimen: Trimethoprim-sulfamethoxazole 3–5 mg/kg 8th hourly OR ciprofloxacin 400 mg twice daily

• Malassezia furfur

• Preferred regimen: Amphotericin B
• Altered regimen: Voriconazole

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Mediastinitis, acute

• Treatment

• Preferred regimen: Clindamycin 450 mg IV q 6 h plus Ceftriaxone 2 g once/day, for at least 2 weeks.

• Prophylaxis

• Methicillin susceptible staphylococcus aureus infection

• Preferred regimen: Second generation cephalosporin.

• Methicillin susceptible staphylococcus aureus infection

• Preferred regimen: Vancomycin

Note: Preoperative antibiotics should be administered to all patients to reduce the risk of mediastinitis in cardiac surgery.

A deep sternal wound infection should be treated with aggressive surgical debridement in the absence of complicating circumstances.

Primary or secondary closure with muscle or omental flap is recommended. Vacuum therapy in conjunction with early and aggressive debridement is an effective adjunctive therapy.

Use of a continuous intravenous insulin protocol to achieve and maintain an early postoperative blood glucose concentration less than or equal to 180 mg/dL while avoiding hypoglycemia is indicated to reduce the risk of deep sternal wound infection.

The use of intranasal mupirocin is reasonable in nasal carriers of S. aureus.

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Myocarditis, viral

Note: Mainstay of therapy for myocarditis is supportive care and standard management of CHF. Ribavarin and interferon alpha improved survival in mice with acute myocarditis

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Pericarditis, fungal

• Fungal Pericarditis

• Empiric therapy : Fluconazole, Ketoconazole, Itraconazole, Amphotericin B, Liposomal amphotericin B or Amphotericin B lipid complex is indicated.

• Histoplasmosis

• Preferred regimen: Nonsteroidal anti-inflammatory drugs given during 2–12 weeks.

Note: Corticosteroids and NSAIDs can support the treatment with antifungal drugs. Pericardiocentesis or surgical treatment is indicated for haemodynamic impairment. Pericardiectomy is indicated in fungal constrictive pericarditis.

• Nocardiosis

• Preferred regimen: Sulfonamides are the drugs of choice.

Note: Corticosteroids and NSAIDs can support the treatment with antifungal drugs. Pericardiocentesis or surgical treatment is indicated for haemodynamic impairment. Pericardiectomy is indicated in fungal constrictive pericarditis.

• Actinomycosis

• Preferred regimen: Combination of three antibiotics including Penicillin.

Note: Corticosteroids and NSAIDs can support the treatment with antifungal drugs. Pericardiocentesis or surgical treatment is indicated for haemodynamic impairment. Pericardiectomy is indicated in fungal constrictive pericarditis.

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Pericarditis, tuberculous

• Preferred regimen: 2 months of Isoniazid 5 mg/kg (300 mg) OD AND Rifampicin 10 mg/kg (600 mg) OD AND Pyrazanamide 1,500 mg OD AND Ethambutol 1,200 OD followed by 4 months of Rifampicin 10 mg/kg (600 mg) OD AND Pyrazanamide 1,500 mg OD. Prednisolone 1–2 mg/kg per day for 5–7 days is also given and is progressively reduced to discontinuation in 6–8 weeks.
• Pediatric dose: Isoniazid 10–15 mg/kg (300 mg); Rifampin 10–20 mg/kg (600 mg); Pyrazinamide 15–30 mg/kg (2.0 g); Ethambutol 15–20 mg/kg daily (1.0 g).

Note: Intrapericardial drainage is done if needed. If constriction develops inspite of medical therapy, pericardiectomy is indicated.

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Pericarditis, viral

• Viral pericarditis

• CMV pericarditis

• Preferred regimen: immunoglobulin 1 time per day 4 ml/kg on day 0, 4, and 8; 2 ml/kg on day 12 and 16.

Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.

• Coxsackie B pericarditis

• Preferred regimen: Interferon alpha or beta 2,5 Mio. IU/m2 surface area s.c. 3×per week.

Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.

• Adenovirus and parvovirus B19 perimyocarditis

• Preferred regimen: Immunoglobulin 10 g intravenously at day 1 and 3 for 6–8 hours

Note: Symptomatic treatment is given to the patients with viral pericarditis while in large effusions and cardiac tamponade pericardiocentesis is necessary. The use of corticosteroid therapy is contraindicated except in patients with secondary tuberculous pericarditis, as an adjunct to tuberculosis treatment. Drainage, if needed is done.

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Rheumatic fever, primary prophylaxis

• Preferred regimen: Penicillin V (Phenoxymethyl penicillin) 500 mg 2 to 3 times daily oral for 10 days OR Amoxicillin 50 mg/kg once daily (maximum 1 g) oral for 10 days OR Benzathine penicillin G IM 600 000 U for patients ≤27 kg (60 lb); 1 200 000 U for patients >27 kg (60 lb) once.
• Alternative regimen: Narrow-spectrum Cephalosporin†(Cephalexin, Cefadroxil) oral for 10 days OR Clindamycin 20 mg/kg per day divided in 3 doses (maximum 1.8 g/d) oral for 10 days OR Azithromycin 12 mg/kg once daily (maximum 500 mg) oral for 5 days OR Clarithromycin 15 mg/kg per day divided BID (maximum 250 mg BID) oral for 10 days.

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Rheumatic fever, secondary prophylaxis

• Preferred regimen: Penicillin G benzathine 1.2 million units IM every 4 wk OR Penicillin V potassium 250 mg orally BID OR Sulfadiazine 1 g orally once daily OR Macrolide or Azalide antibiotic (for patients allergic to Penicillin and Sulfadiazine) varied dose.
• Note: Duration of secondary prophylaxis for rheumatic fever differs for different scenarios. For Rheumatic fever with carditis and residual heart disease (persistent VHD) 10 y or until patient is 40 y of age (whichever is longer). For Rheumatic fever with carditis but no residual heart disease (no valvular disease) 10 y or until patient is 21 y of age (whichever is longer). For Rheumatic fever without carditis 5 y or until patient is 21 y of age (whichever is longer).

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Septic pelvic vein thrombophlebitis

• Based on the CT and MRI findings septic pelvic vein thrombophlebitis is classified into following categories for management..

• Right ovarian vein thrombosis

• Preferred regimen: Ertapenem 1 g daily for 7 days AND Enoxaparin (1 mg/Kg) initially AND 3–6 months of Warfarin (INR 2.5) OR Gentamicin 4 mg/kg AND Ampicillin 2 g AND Clindamycin 1200 mg for 7 days AND Enoxaparin (1 mg/Kg) initially AND 3–6 months Warfarin (INR 2.5).

Note: Repeat CT scan after 3 months. If negative, stop anticoagulation. If still positive for thrombi, anticoagulate for 3 additional months.

• Pelvic branch vein thrombosis

• Preferred regimen: Ertapenem 1 g daily for 7 days AND Enoxaparin (1 mg/Kg) for 2 weeks OR Gentamicin (4 mg/kg) AND Ampicillin 2 g AND Clindamycin 1200 mg for 7 days AND Enoxaparin (1 mg/Kg) for 2 weeks.

• Negative for pelvic thrombi

• Preferred regimen: Ertapenem 1 g daily for 7 days AND Enoxaparin (1 mg/Kg) for 1 weeks OR Gentamicin (4 mg/kg) AND Ampicillin 2 g AND Clindamycin 1200 mg for 7 days AND Enoxaparin (1 mg/Kg) for 1 weeks.

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